Revista Brasileira de Geriatria e Gerontologia ISSN: 1809-9823 ISSN: 1981-2256 Universidade do Estado do Rio Janeiro Assis, Elisa Priscila Sousa de; Macêdo, Barbara Gazolla de; Oliveira, Hanna Sette Camara de; Rezende, Poliana de Paula Dias; Antunes, Carlos Maurício Figueiredo Anemia and the frailty syndrome amongst the elderly living in the community: a systematic review Revista Brasileira de Geriatria e Gerontologia, vol. 21, no. 2, March-April, 2018, pp. 223-231 Universidade do Estado do Rio Janeiro DOI: 10.1590/1981-22562018021.170100 Available in: http://www.redalyc.org/articulo.oa?id=403855510012 How to cite Complete issue Scientific Information System Redalyc More information about this article Network of Scientific Journals from Latin America and the Caribbean, Spain and Portugal Journal's homepage in redalyc.org Project academic non-profit, developed under the open access initiative http://dx.doi.org/10.1590/1981-22562018021.170100 Anemia and the frailty syndrome amongst the elderly living in the community: a systematic review Review Articles 223 Elisa Priscila Sousa de Assis1,2 Barbara Gazolla de Macêdo1,3 Hanna Sette Camara de Oliveira1 Poliana de Paula Dias Rezende1 Carlos Maurício Figueiredo Antunes1 Abstract Objective: To evaluate the association between anemia and the onset of the frailty syndrome amongst the elderly living in the community. Method: A systematic literature review of articles from the MEDLINE and LILACS databases published in English, Spanish and Portuguese over the last ten years was carried out. Articles were included in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Keywords: Anemia. Frayl Results: The search identified 193 studies. After deleting duplicated articles and applying Elderly. Sarcopenia. Muscle the exclusion criteria only seven articles remained. Three articles used standardized Strength. Wallking Speed. criteria to define frailty, whereas four evaluated functional capacity as a synonym for the frailty syndrome. Conclusion: Anemia was related to a worsening of functional capacity and to the presence of the frailty syndrome in elderly persons living in the community. However, the risk of bias in the studies was high in relation to the selection of the criteria and instruments used to assess and define frailty. 1 Instituto de Ensino e Pesquisa da Santa Casa de Belo Horizonte, Programa de Pós-graduação Stricto Sensu em Medicina e Biomedicina, Laboratório de Epidemiologia. Belo Horizonte, Minas Gerais, Brasil. 2 Fundação Hospitalar do Estado de Minas Gerais (FHEMIG), Hospital Regional de Barbacena Dr. José Américo, Fisioterapia Respiratória. Barbacena, Minas Gerais, Brasil. 3 Instituto da Previdência dos Servidores do Estado de Minas Gerais (IPSEMG), Departamento de Fisioterapia. Belo Horizonte, Minas Gerais, Brasil. Research funding: National Council for Scientific and Technological Development (CNPq) (CMFA - 1A Research Grant) and Research Support Foundation of the State of Minas Gerais (FAPEMIG) (Projeto CDSAPQ-0078415). Correspondence Barbara Gazolla de Macêdo [email protected] Rev. Bras. Geriatr. Gerontol., Rio de Janeiro, 2018; 21(2): 223-231 INTRODUCTION the condition and for preventive interventions that can delay or prevent the progression of the syndrome, Aging is accompanied by physiological factors preserving functional independence for longer10,11. that can cause reduced functional capacity. When combined with chronic degenerative diseases, The probable association between the frailty functional dependence can be a determinant for the syndrome and anemia is of great importance to the deterioration of quality of life1,2. The gastrointestinal area of geriatrics, as these are common phenomena 224 system and bone marrow also suffer during aging, in this population and when combined may present leading to a greater frequency of anemia in this a more serious clinical outcome3. population1. The aim of this study was to evaluate, through a According to the World Health Organization, systematic literature review, the association between anemia is defined as a concentration of hemoglobin anemia and the frailty syndrome in elderly persons of <120g/l for women and <130g/l for men3. The living in the community. prevalence of anemia increases with age and has been reported in more than 20% of elderly persons aged 85 years or more, over 10% of elderly persons METHOD living in the community and in around 50% of institutionalized elderly persons4. The reduction of The literature review used the MEDLINE and hemoglobin may be due to nutritional deficiency, LILACS databases to search for articles in English, chronic inflammation or unexplained factors5. Spanish and Portuguese. As the concept of frailty Anemia is associated with reduced mobility, cognitive has been established in literature in the last decade, ability and quality of life and increased mortality. the review was limited to publications from the last Some studies have associated the reduction of 10 years . The selected descriptors were: frail, elderly, hemoglobin levels with the development of the anemia, sarcopenia, motor activity, muscle strength, frailty syndrome6,7. mobility limitation, walking. Articles with the key words in the titles or abstracts and published by Frailty is a clinical syndrome that leads to September 2016 were sought. The search strategy multisystem decline and reduced energy reserves and the Boolean descriptors and operators was as and homeostatic balancing ability following a follows: destabilizing event. It is multifactorial and associated with immunosenescence and inflammatory tw: [anemia AND ("Capacidade funcional" OR processes3,8. Immunosenescence is accompanied by funcionalidade OR "Independencia funcional" OR dysregulation of the immune system and an increase "Atividade funcional" OR "capacidad funcional" in the production of inflammatory cytokines (IL-6, OR funcionalidad OR "independencia funcional" TNF-alpha, IL-1), producing a chronic low-grade OR "actividad funcional" OR "Functional capacity" inflammatory state. The mechanism by which OR functionality OR "functional independence" the increase of inflammatory cytokines leads to OR "functional activity" OR sarcopenia OR "Motor the development of the frailty syndrome is still Activity" OR "Actividad Motora" OR "Atividade uncertain, but evidence indicates the catabolic Motora" OR "Muscle Strength" OR "Fuerza action of this mediator9. The criteria that define Muscular" OR "Força Muscular" OR "Mobility frailty are controversial; the most used are decreased Limitation" OR "Limitación de la Movilidad" OR muscle strength, exhaustion, reduced gait speed, "Limitação da Mobilidade" OR “walking” OR reduced physical activity and unintentional weight “caminata” OR “caminhada” OR “frail elderly”)] loss9. However, some authors suggest the inclusion AND (instance:"regional") AND [limit:("aged") of other criteria such as nutrition, comorbidities AND la: ("en" OR "es" OR "pt") AND year_ and socioeconomic aspects3,8. The establishment of cluster:("2013" OR "2014" OR "2009" OR "2008" precise criteria and the standardization of instruments OR "2012" OR "2015" OR "2007" OR "2010" OR that evaluate frailty are important for the diagnosis of "2006" OR "2011" OR "2016")]. Anemia and frailty in elderly persons living in the community Observational-type studies addressing anemia, was elaborated based on the population, exposure/ frailty and/or functional capacity in the elderly intervention, control and outcome (PECO) domains13. living in the community were adopted as inclusion criteria. Articles that approached hospitalized or The assessment of the risk of bias in the articles institutionalized elderly people undergoing cancer included in the analysis was performed using an treatment in the postoperative period and with serious adapted version of the Newcastle-Ottawa Scale diseases such as rheumatologic, renal, cardiac and (Chart 1). The original scale evaluates the quality pulmonary insufficiency, were excluded. The selection of observational studies and contains eight items 225 and qualification of articles were carried out by two that analyze three dimensions, with several options independent reviewers following the inclusion criteria. for each item. In this review, the questions were In the case of disagreement, the articles were read and adjusted to investigate exposure and outcome (frailty discussed together. The review followed the specific syndrome), and the risk of bias was divided as follows: methodological guidelines for observational studies12. low, uncertain, and high risk14. To select the data of the articles, the Preferred Reporting Items for Systematic Reviews and Meta- This review was registered with the International Analyzes (PRISMA) criteria were applied, and for Prospective Register of Systematic Review the analysis of the selected articles an instrument (PROSPERO) under number CRD42017057567. Chart 1. Adaptation of Newcastle-Ottawa Scale for evaluation of quality of studies. Belo Horizonte, Minas Gerais, 2017. Exposure a) Secure record + primary measures * (low risk of bias) Obtaining the independent variables b) Structured interview + primary measures, without knowledge of the outcome * (low risk of bias) c) Interview with knowledge of the outcome (high risk of bias) d) Non-secure sources and self-assessment (high risk of bias) e) Does not describe clearly (uncertain risk of bias) Outcome Is the assessment of frailty adequate? a) Yes, (low risk of bias) b) Yes, according